Provider Demographics
NPI:1639310386
Name:LONG, LORY ANNE (RDH)
Entity type:Individual
Prefix:
First Name:LORY
Middle Name:ANNE
Last Name:LONG
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:WI
Mailing Address - Zip Code:54656-2019
Mailing Address - Country:US
Mailing Address - Phone:608-386-5859
Mailing Address - Fax:
Practice Address - Street 1:615 10TH ST S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4768
Practice Address - Country:US
Practice Address - Phone:608-782-4054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-10
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9727-16124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist